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Biliary Colic

Risk factors

  • Constant dull pain and not colicky
  • In RUQ/Epigastrium radiating to the back - right shoulder blade
  • Lasts 30min - 6h
  • Postprandial or nocturnal
  • Hormonal or neural stimuli forcing a stone/sludge in the GB outlet
  • The 5 F's
  • Pregnancy (or history of one)
  • Oral contraception - high doses of Oestrogen therapies
  • Family history of gall stones
  • Recent weight loss (bariatric surgery)
  • Crohn's disease or IBS
  • Cirrhosis
  • Medications: Ceftriaxone, Octreotide
  • Elderly patients are more likely to go from asymptomatic to serious complications without biliary colic

Clinical presentation

Uncomplicated gall stone disease

What is cholecystitis?

  • Biliary colic
  • Diaphoresis
  • Nausea and vomiting
  • Atypical symptoms: chest pain; nonspecific abdominal pain; bloating; heartburn; belching; nausea and vomiting with no biliary colic; fullness after meals
  • Acute (calculous) cholecystitis
  • Acalculous cholecystitis
  • Chronic cholecystis

Clinical presentation

Biliary tract disease

Acute cholecystitis

  • RUQ/epigastric pain > 6h
  • Pyrexia
  • Tachycardia
  • Nausea and vomiting
  • Anorexia
  • History of food ingestion 1h or more prior to symptoms
  • Possible signs of sepsis
  • Murphy's sign

Facts

  • Asymptomatic gall stones
  • Biliary colic
  • Cholecystitis
  • Choledocholithiasis
  • Cholangitis
  • Mirrizi syndrome
  • Cholelithiasis - gall stones in the gall bladder and biliary tree
  • Common for western countries
  • 15% of UK adults (6% men and 9% women
  • 80% asymptomatic and 20% with complications

Laboratory studies

Biliary Colic and Acute Cholecystitis

Management of acute cholecystitis

Polyp vs gall stone

Imaging

  • Mirizzi Type II - erosion from the calculus from the cystic duct into the common hepatic duct or CBD producing cholecystocholedochal fistula

Note the acoustic shadow!

Ultrasonography

  • Sensitivity for gall stones is 84% and specificity 99%
  • For diagnosis of cholecystitis 88% and 80% respectively
  • Gall bladder wall thickening (> 4 - 5mm) or oedema (double wall sign)
  • Sonographic Murphy's sign
  • The accuracy of transabdominal ultrasound is operator dependent!

Sludge

No echoic shadow! Gravity dependent.

  • Hospital admission for supportie care
  • Fluid resuscitation/replacement, correction of electrolytes
  • Pain relief
  • Antibiotics

1st line - Co-amoxiclav + Gentamicin

2nd line - Co-tromoxazole + Metronidazole + Gentamicin

  • Cholecystectomy
  • Drainage

Categorization of patients with gall stones

What is Mirizzi syndrome?

  • Category 1 - gallstones on imaging studies but without symptoms (incidental gall stones)
  • Category 2 - typical biliary symptoms and gall stones on imain studies with no evidence of complications (uncomplicated gall stone disease)
  • Category 3 - atypical symptoms and gall stones on imaging studies
  • Category 4 - typical biliary symptoms but with no gall stones on imaging studies
  • Type I - compression of the common hepatic duct or common bile duct by a stone impacted in the cystic duct or Hartman's pouch
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